Diverticular Disease

The disease that is becoming more prevalent

Diverticular disease is a relatively common condition that happens as a result of aging muscles in the wall of the large bowel. Small bulges or pockets develop in the lining of the intestine, and when those pockets become inflamed or infected, diverticulitis occurs, and it’s estimated that five percent of the population will develop these pockets by the age of 40, and at least 50 percent by the time they reach age 80.

While diverticulitis is not a commonly known topic, it’s becoming more and more prevalent in The Bahamas, according to Dr. Ross Downes, general and laparoscopic surgeon. He says it’s a disease for which prevention is definitely better than cure.

While in most cases, rest, a liquid diet and some oral antibiotics can resolve the issue, for patients with severe symptoms, or who have had two or more severe attacks of diverticulitis, surgery may be necessary.

“In diverticulitis, when these pouches are formed, sometimes stool gets caught in the base of them, that [waste] that gets caught in the base of them leads them to have infection, they break down and they perforate, or create a hole. That hole makes [waste] seep into the intestines.”

Dr. Downes said diverticular can happen two ways — the body makes them happen, or a person is born with them.

When the pouches form the doctor said they put a person at risk for one of four things — bleeding, perforation and inflammation, or a stricture, as it blocks off the intestine and they are unable to pass their fecal matter, or have pain.

“You may not realize you’re having an attack — some people think it’s just gas, and they have recurring attacks of this so-called gas pain, and then the pain becomes constant, they have it all the time, it happens in episodes. They don’t realize a pattern and it becomes something that changes their lifestyle and how they eat because of how bad the pain is.”

Speaking at the recent Doctors Hospital Distinguished Lecture Series, Dr. Downes said one of the main theories behind why people develop diverticular is because of a diet low in fiber. And he said this is one of the main reasons why the disease is starting to become more common in The Bahamas.

“We have lot of fast food chains, a lot of quick food. We don’t eat at home as much, and those meals that we eat are a lot lower in fiber than typically what we ate in the past. Because of that decrease in fiber, you have a decrease stool bulk. And it’s important that your stools are bulky, because it allows your intestines to compress against them very easily and allows you to pass your stool out. When that mass is decreased the bowel has to work a lot harder and there’s a lot more pressure within the intestine. That pressure causes those areas of weakness, which is where the pouches formed, which is where diverticular forms to develop that disease. So we’re finding that a lot more people in our population are having a lot more symptoms from their diverticular. That decrease in fiber weakens the intestine quite a bit, and exposes and increases risk for more and more pouches, or diverticular.”

How it happens

The inflammation erodes and break down means that human waste matter seeps into the abdominal cavity forcing the body to start trying to resist the infection. That starts the inflammation process. The doctor said that process depends on how a person’s body respond, whether it’s mild with just a little pain, or severe during which waste continues to seep into the abdomen and they become very ill. Both conditions, he said, would bring a person to the hospital.

“If you do not have a strong enough immunity, then you’re not able to keep that infection in one place and localize it. So what happens is that infection then spreads throughout the abdomen, and you get pain throughout the entire abdomen. The problem is not just the pain, the problem is also the stress on your body. Sometimes the infection can be smoldering which means it’s not significant enough to make you think you need to go to the hospital or seek treatment. And because you have pain in the abdomen and it can mimic a lot of other conditions.”

“When we look at diverticula, under the age of 40, only five percent of us will have those. It does mean we will have symptoms, it just means that they’re present, and it goes up in age, so by age 50 and older, almost half of us have diverticular; when we get to the age of 80, almost all of us, 80 percent of us have diverticular, so it means the older we get, the more at risk we are for having diverticular, which means the more at-risk we are for having symptoms of diverticular.”

The doctor says there is no difference between men and women when it comes to this disease. He said they are both equally exposed to developing symptoms. But he added that it’s rare in undeveloped countries where they tend to have high-fiber diets.

At Doctors Hospital, he said the diagnosis is quite significant.

“If we had to roughly estimate, if you come into the hospital and you’re over 50, one in 10 people that present to us would have some problem with their diverticular.”

He said the 20 percent of people require surgical therapy, a statistic that he said is not good, and is actually a high number.

“We’re looking at patients over the age of 50, having a significant amount of diverticular, which means they are at increased risk of presenting with the condition, and which means they are at increased risk for having some type of surgery. The problem itself is not just the surgery, the problem is also that these patients present at this age tend to have something else going on … hypertensive, have a heart problem, so not only are they at risk for a condition that can be quite devastating, but they also have other problems that we have to deal with at the same time.”

In terms of race, the majority of people he said would have pain on their left side, as that is where the piece of the intestine that is most at-risk for developing diverticulitis is.

“Once you’re over the age of 50, one of our first diagnoses, and high up on that list is diverticulitis.”

With the influx of other races into the population, he said medical professionals now have to look out for when they see a patient of Asian descent present to the hospital with right-sided pain. He said they tend to get their diverticular on the right side.

“There is no relation between the male and female and, of course, we see that the disease increases with age.”

Other than having the classic left-sided pain, patients usually don’t have an appetite and they almost always have high-grade fever because of the inflammatory process and the body trying to fight the waste matter that’s spilled out into their abdomen, and try to contain it. He said they present with their heart beating fast, looking dehydrated, blood pressure not normal and lower than usual.

“Once you present to us with left-sided pain, have a high fever and are sick and ill, our consideration in all cases, our number one diagnosis, especially if you’re over the age of 50 is that there’s a perforation there — stool has already spilled out. We now have to determine how much stool has spilled out, and how your body has responded to that infection. In those situations, almost all times you will be admitted to hospital.”

With diverticular patients would either have inflammation or bleeding and that very few would have both symptoms when they present to the hospital.

Worst case scenario

If by some chance, medical professionals err in their diagnosis of the disease, Dr. Downes said organs can get stuck together, and holes happening across the organs, resulting in the waste going into organs it’s not supposed to — such as the bladder. In females he said the vagina can be negatively connected, and if the infection is bad enough, waste matter would come out of it, which he said is not a good sign and has to be dealt with immediately.

“One of the considerations that is not as bad is a change in your bowel habits is when two pieces of intestine connect to each other. It changes how your body is able to absorb a lot of its nutrients, because it bypasses a lot of your intestine which essentially doesn’t work, so you have a lot of diarrhea, you’re losing weight, you don’t really get the nutrients from your food, and that’s because if you have diverticulitis, you may have developed a fistula, abnormal connection between one piece of the intestine and the colon.”

Dr. Downes said it’s important for doctors to make the right diagnosis. He said there are a significant amount of different infections and organs involved that can mimic diverticular. In making that diagnosis, that determines how a patient is treated.

He said it’s important that they take a good history, understand the patient’s symptoms, and why they presented, and examine a patient in completeness including blood tests to looks for any infection.

“The good thing about diverticulitis is that in a lot of patients there is an elevated white count or elevated number of cells that fight infection. The problem is that it’s not specific for the disease, so we know there is some inflammation and a problem, but to determine if it’s diverticulitis, we have to combine that with the history and how we’ve examined you, and then it will give us an answer.”

He said abdominal x-rays also aid doctors in their determination as it allows them to see air outside the bowel or if the layer of the intestine wall is thickened, which he said tells them something abnormal is happening. But that a CT scan gives even more information and allows them to be a lot more specific and help doctors localize the exact piece of intestine involved.

“We can see some signs on there that tells us there is a perforation in the bowel wall, and some of the stool that has seeped out, and how bad it is.”

Treatment

At Doctors Hospital they’ve added a CT colonoscopy to their arsenal in the diverticulitis fight as it gives them even more information, he said.

“Doctors Hospital is probably one of the pioneers in the region in adding this into their arsenal in treating patients, because what we can do now is we can offer a safe procedure that will give us a lot of information about exactly what is going on. It can tell us what’s happening with the lining of the entire intestine and be done pretty quickly.”

For mild diverticulitis, the recommendation is rest, a liquid diet and oral antibiotics; after a few days a soft, low-fiber diet is introduced, and after one month, a high-fiber diet can be started. A colonoscopy is suggested at four to six weeks as diverticulitis can mimic colon cancer.

For severe symptoms the patient is admitted to hospital, given intravenous fluids and antibiotics, and is on bed rest and can intake nothing by mouth until the symptoms subside.

“About 20 percent of people who have diverticulitis require surgery because the condition does not improve. But prevention is better than cure, which is why we recommend screening colonoscopies and high fiber diets and lifestyle changes, because you don’t want to get to the point of even the first stage, because you end up with a whole bunch of problems and it’s difficult to treat,” said Dr. Downes.

In surgery for diverticulitis, he said, at Doctors Hospital they have moved into performing more minimally invasive surgeries to lessen the stress on the body, and of complications from wound infection, wound break down, and hernia breaking down which were all feared complications.

Only in very ill patients, where they have to get in quickly and see what’s going on will they do regular surgery, because they don’t have the luxury of time to get the patient prepared as they’re not stable enough to tolerate that type of procedure.

“You need to get in that belly, get them washed out and solve the leakage,” he said.

“Once you are the ideal candidate, meaning that you are not sick, not unstable to tolerate the procedure, we do one tiny incision by the belly button and are able to go in there, wash out the belly, deal with the diseased part of the intestine, connect it together or bring out the end if we need to. So the less incisions or size of incisions means the less stress your body is going to tolerate, as well as the decreased number of complications that we find associated now that we are doing more of these minimally invasive procedures.”

Stressing that prevention is better than cure, Dr. Downes encourages people to ingest a high-fiber diet, recognize the condition, and seek medical advice as early as possible.